3/29/2017. Disclosure of Relevant Financial Relationships. Disclosure of Relevant Financial Relationships. Cytological Findings CASE HISTORY

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1 UNUSUAL/INTERESTING CASES WITH A MESSAGE Esther D. Rossi MD PhD MIAC Division of Anatomic Pathology and Cytology Catholic University of Sacred Heart Rome, Italy Disclosure of Relevant Financial Relationships Disclosure of Relevant Financial Relationships USCAP requires that all planners (Education Committee) in a position to influence or control the content of CME disclose any relevant financial relationship WITH COMMERCIAL INTERESTS which they or their spouse/partner have, or have had, within the past 12 months, which relates to the content of this educational activity and creates a conflict of interest. I do not have any conflict of interest 48 y/o man 1.5 cm left parotid nodule CASE HISTORY Evaluation under sonographic guidance (US): Ipervasculated solid encapsulated nodule with a dishomogenous pattern Aspiration performed with two passages with 25 G needles FNAC processed with conventional cytology and liquid based cytology (LBC) Cytological Findings Scanty isolated and numerous solid clusters of cells Small-Medium size cellularity Epithelioid-plasmacytoid and fusiform-spindle cells Round-oval nuclei with finely dispersed or finely granular chromatine Mild atypia Several basaloid features Scanty fibro-vascular fragments Some histiocytes 1

2 How should I sign out this case?? A diagnostic dilemma Could they help me together?? 2

3 Take a deep breath: looking for clues Possible differential diagnoses BENIGN MALIGNANT Morphology? Age? Pattern? Pain? LET S WORK ON THEM Pleomorphic adenoma Basal cell adenoma myoepithelioma Adenoid cystic carcinoma Jurczyk M et al, Diagn Cytopathol 2014 Can I refine my cytological diagnosis? Investigations which can be carried out on cytologic samples immunocytochemistry ISH flow-cytometry mutational analysis 3

4 CK14 so how can I sign out this case? But also positivity for: p63 Me after wringing my brain for the case!!!! 2 MONTHS LATER HISTOLOGY: Parotid gland (6,6x4.8x2.7 cm) with a 1,5 cm nodule 1) Capsulated tumor mass 2) Proliferation of ovoid elements with a reticular pattern 3)Round ovoid nuclei with clearing and nuclear pseudoinclusions 4)Spindle component 5)no significant atypia 6)No mitoses MY CYTOLOGICAL DIAGNOSIS: Well differentiated neoplasm with basaloid features Positivity CK 14 S100 CAM 5.2 CK 5/6 (focal) p63 (focal) Calponin SMA Negativity CD117 SMMHC 4

5 The final histological diagnosis: DIAGNOSIS? NEXT EXIT Reticular myoepithelioma The role of FNAC in salivary gland lesions IS FNA ACCURATE AND FEASIBLE? Rapid, safe, few complications Preoperative distinction of benign and malignant lesions (aid in management) IS FNA ACCURATE AND FEASIBLE? Wide range of sensitivity ( from 62 to 97.6%) Specificity (from 94.3 to 100%) High diagnostic accuracy for benign lesions but lower for malignant tumors Accuracy of type-specific diagnoses of malignant lesions is quite poor Benign masses and inflammatory diseases account for over 80% of all lesions Carcinomas and lymphomas are 10% of all salivary FNA 5-10% inadequate rate reported by literature 5

6 The development of an international system Scientific Terminology < aka Nomenclature > As ideas are preserved and communicated by means of words, it necessarily follows that we cannot improve the language of any science, without at the same time improving the science itself; neither can we, on the other hand, improve a science without improving the language or nomenclature which belongs to it Antoine-Laurent Lavoisier ( ), French chemist 6

7 On Reporting Terminology - Why do we need a reporting system for salivary gland cytology? an accurate cytologic diagnosis of disease is both possible and desirable: therefore, the reports should be expressed in simple language that can be readily understood by the clinician. Current reporting confusion: Diversity of diagnostic categories, vs. Descriptive reports (no categories), vs. Surgical pathology terminology Leo Koss Diagnostic Cytology and its Histopathologic Bases, 1 st ed, 1961 General agreement on the need for a defined set of diagnostic categories for salivary gland FNA Clarity of communication (implicit cancer risk) Exchange of data across institutions The Milan System for Reporting Salivary Gland Cytopathology Why Milan? The Milan System for Reporting Salivary Gland Cytopathology Sponsored by the ASC and the IAC practical classification system that will be user-friendly and internationally accepted evidence-based system with a useful format for clinicians The classification system and ROM for the diagnostic categories was further refined according to literature The Benefits of a Uniform Reporting System for Salivary Gland Cytopathology The Milan System for Reporting Salivary Gland Cytopathology Improve communication between pathologists and clinicians Improve patient care Facilitate cytologic-histologic correlation Promote research into the epidemiology, molecular biology, pathology, and diagnosis Foster sharing of data from different laboratories for collaborative studies Core Group Co-Chairs: Bill Faquin & Esther Diana Rossi Zubair Baloch Guliz Barkan Maria Pia Foschini Daniel Kurtycz Marc Pusztaszeri Philippe Vielh 7

8 1) Non-Diagnostic 2) Non-Neoplastic Proposed Classification Scheme 3) Atypia of undetermined significance (AUS) 4) Neoplastic: a) Benign b) Uncertain malignant potential (SUMP) 5) Suspicious for Malignancy 6) Malignant The Milan System for Reporting Salivary Gland Cytopathology Participants: 47 Members from 15 Countries Cytopathologists, Surgical Pathologists, Molecular Pathologists, ENT Surgeons 1. Overview of Diagnostic Terminology and Reporting: Core group, Bruce Wenig, Raja Seethala, Andrew Field, Nora Katabi 2.Nondiagnostic/Unsatisfactory: Mariapia Foschini and Esther Diana Rossi (ead), Kayoko Higuchi, Ivana Kholova, Jhala Nirag,, Makato Urano, Laszlo Vass, Philippe Vielh, 3. Non-neoplastic: Bill Faquin (lead), Massimo Bongiovanni, Fabiano Callegari, Sule Canberk, Tarik Elsheik, Dan Kurtycz, Oscar Lin, Marc Pusztaszeri 4. AUS: Marc Pusztaszeri (lead), Zubair Baloch, Bill Faquin, Diana Rossi, Laura Tabatabai 5. Neoplastic (benign & SUMP): Zubair Baloch (lead), Jeff Krane, Lester Layfield, Marc Pusztaszeri, Jerzey Klijanienko, Ritu Nayar, Celeste Powers, Pinar Firat, Guido Fadda 6.Suspicious for Malignancy: Esther Diana Rossi (lead), Syed Ali, Ashish Chandra, Andrew Field, Yun Gong, Zarha Maleki, Bo Ping, He Wang 7.Malignant: Güliz Barkan (lead), He Wang, Philippe Vielh, Stefan E. Pambuccian, Swati Mehrotra, Mousa Al-Abbadi, Eva Wojcik 8. Ancillary Studies: Mark Pusztaszeri (lead), Jorge Reis-Filho, Fernando Schmitt, Raja Seethala 9. Clinical Management: Mark Varvares (lead ), Piero Nicolai, Mandeep Bajwa CLASSIFICATION SYSTEM Non-Diagnostic Insufficient quantitative and/or qualitative cellular material to make a cytologic diagnosis 10% would be a target maximum rate Includes aspirates with benign elements only Includes non-mucinous cyst contents Non-Neoplastic Atypia of Undetermined Significance (AUS) Cannot entirely exclude a neoplasm. Specimens lacking evidence of a neoplastic process: Inflammatory, metaplastic, and reactive (I.e acute, chronic, and granulomatous sialadenitis,sialadenosis, etc ) Reactive lymph nodes (flow cytometry is needed) Clinico-radiological correlation is essential to ensure that the specimen is representative of the lesion Heterogeneous category A majority will be reactive atypia or poorly sampled neoplasms Specimens are often compromised (eg, air-drying, blood clot) Should be used rarely (<10 % of all salivary gland FNAs) 8

9 Neoplasm Suspicious for Malignancy i) Benign Neoplasm: Reserved for clear-cut benign neoplasms This category will include classic cases of PA, WT, lipoma, etc Aspirates which are highly suggestive of malignancy but not definitive ii) Salivary Gland Neoplasm of Uncertain Malignant Potential: Diagnostic of a neoplasm; however, a diagnosis of a specific entity cannot be made. A malignant neoplasm cannot be excluded. Often high grade carcinomas with limited sampling or other limitation Malignant THE HIGH NOON OF SALIVARY CYTOLOGY?? Aspirates which are diagnostic of malignancy Sub-classify into specific types and grades of carcinoma: e.g. low grade vs high grade "Other" malignancies such as lymphomas, sarcomas and metastases are also included in this category and should be specifically designated. Milan System? Descriptive classical cytology? The Milan System for Reporting Salivary Gland Cytopathology TAKE HOME MESSAGE FNA shows a high diagnostic accuracy in salivary gland lesions The ROM will depend upon the nature of the Specimen and the salivary gland site. The distinction among pleomorfic adenoma, myoepithelioma and basal cell adenoma remains difficult in many cases and it has no significant impact on the clinical implication Liquid based cytology may be a complementary feasible/reliable method FNAC with a classification system may offer valid information for the approach to the management of parotid lumps 53 A classification system requires robust testing in terms of validity and reproducibility 9

10 Deadline for the Atlas: SUMMER 2017 FOR YOUR ATTENTION 10